Multiple well defined radiolucencies / dental courses

MULTIPLE WELL DEFINED RADIOLUCENCIES
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INDIAN DENTAL ACADEMY
Leader in continuing Dental Education

Anatomic variants:
Focal osteoporotic bone marrow defects
Separate marrow spaces
Multiple post extraction sockets

 Pathology :
Multiple cysts or
granulomas
Basal cell nevus
syndrome
Multiple myeloma
Metastatic carcinoma
Langerhan’s cell disease
 Rarities
Ameloblastoma
Cherubism
Craniofacial dysostosis
Florid cementosseous dysplasia
Giant cell granuloma
Hyperparathyroidism
Lymphomas
Neurofibromatosis
Noonan’s syndrome
Oxalosis
Papillon-lefevre syndrome
Scleroderma
Traumatic bone cyst
Systemic sclerosis

Focal osteoporotic bone marrow
defects
 May produce the radiographic image of a
cyst like rl
 They are comon in mandible post region
 Female
 r/f varies from cyst like to multilocular to
irregular and borders are well defined
 Rarely shows cortical expansion
 They are seen at the apices of the teeth

Focal osteoporotic
defects

Focal osteoportoic defect

Multiple extracted sockets

Marrow spaces
The trabecular pattern in the
posterior mandible is quite variable,
generally showing large marrow
spaces and sparse trabeculation,

Multiple Cysts Or Granulomas
 Dentigerous cyst
 Radicular cyst
 Primordial cyst

Basal cell nevus syndrome
 It is a autosomal dominant trait with variable
expressivity
 M=F
 Age: 5 & 30 yrs
 Cutaneous & skeletal abnormalities( multiple cysts of
jaw,bifid ribs,vertebral fusion,polydacty,mild
prognastism)
 Ectopic calcification
 Nevoid basal cell carcinoma
 Dyskeratosis on palmar and plantar surfaces
 Jaw cysts –dentigerous cysts,primodial or radicular

MultipleOKCsassociatedwithnevoidbasalcellcarcinomasyndrome.
A,Upperarrowspointtoopacifiedmaxillaryantra;smallerarrowindicatesthe
extensionofoneofthemandibularcysts(lowerarrows)intothebifurcationregion
ofamandibularmolar.

Basal cell nevus syndrome showing multiple
cysts in different parts of mandible

Multiple myeloma
Synonym: Myeloma,Plasma cell myeloma, Plasmacytoma
 It is defined as a chronic, progressive neoplastic
proliferation of the plasma cells which produces
immunoglobulins, occurring principally in the bone
marrow, but which may also appear in other organ
systems
Most common malignancy of bone in adults
 Single lesions –Plasmacytoma
 Multipe lesions-Multiple Myeloma

Clinical features
 4th to 7th
 Male predileciton
 Bone pain , Anemia, low back pain (typical
feature)
 Secondary signs : Amyloidosis, Hypercalcemia
 Bence jones proteins-50% patients
 when clonal proliferation occurs it replaces
cancellous bone later cortical border replacing the
normal RO bone with areas of RL

ORAL FINIDINGS
 Pain, paresthesia;,mucosal ulcerations,swelling, soft
tissue mass, tooth mobility,tooth migration,
Amyloid deposition in the tongue and other oral
tissues, and pathological fracture.

Radiographic findings
 Type 1: Solitary type (similar to bone cyst)
 Type 2: Multiple osteolytic lesions without
marginal sclerosis (a. central type, and b.
peripheral type)
 Type 3: Diffuse osteoporosis with generalized
involvement
 Type 4: Diffuse osteosclerosis.

Diffuse Osteosclerosis
a) Diffuse
b) Focal osteocondensation
c) Bony speculation on the surface of the bone
d) Sclerotic reaction at the rim of lytic lesion.

Radiographic Manifestations
The multiple lesions may be few or many
They are commonly rounded , with eighter well-
defined or fairly well-defined margins but lacks
cortication (punched out) ,some lesions may be
irregular (secondary cancer)

 Adjacent lesions often meet as they enlarge so that a
remnant of bone left between lesions-
 The result of the formation of adjacent lesions is that
the surface of the bone is deformed –rippled
appereance
 Separate areas of bone destruction varying in size
from few mm to many inches
 In advanced cases there are thousands of such
rounded rl scattered - riddled appereance
 Maxilla and mandible are rarely affected
Many very small lesions not over 3mm are seen but
seldom reaches 1cm
Margins are usually fairly sharp

CRITERIA
 Clonal plasma cells are present on biopsy of
bonemarrow or plasmacytoma
 M-protein is present in serum or urine (either
intact immunoglobulin or free light chains)
 Evidence of related organ or tissue impairment is
present (lytic bone lesions; renal insufficiency;
anemia; hypercalcemia; hyperviscosity;
amyloidosis; or recurrent infections).

D/D
 Metastatic tumors

Lateral skull view showing
multiple
punched out radiolucent
lesions scattered throughout
the
entire skull

Multiple Myeloma With Osteoporosis
 It is a very rare entity which involves the
greater part of skeleton and jaws
 Whole of the bone appears unusually dark
and the trabeculae may be diffcicult to
identify –except for the persistacne of cortical
margins
d/d:
Hyperparathyroidism

Solitary myeloma
Jaws are uncommon sites to occur
2 main types:
1st type-An area of bone destruction is well demarcated
from surrounding bone ,some times may be corticated
Sub periosteal new bone may form
Trabeculae –thin or coarse
2nd type-purely destructive with no new bone at the
margins surrounding the tumor ,
The margins shows infilteration
Flat bones- sausage shaped lesions with undulating
margins

Cropped
panoramic
image shows
a solitary
lesion in the
condylar
neck region

Effects on surrounding structure
 Teeth may appear as too RO
 Lamina dura and follicles of impacted tooth
may lose their typical corticated surrounding
bone
 Thinning of lower border of mandible ,or
endosteal scalloping
 Periosteal reaction is rare but if present takes
the form of single RO line or more rarely
sunray appereance

Langerhan Cell Histocytosis
Synonym: Idiopathic histiocytosis,histiocytosis X
 Acute disseminated form –letterer-siwe
disease
 Chronic disseminated form-hand-schuller-
christian
 Chronic localized form-eosinophilic
granuloma

Acute disseminated Chronic disseminated Chronic localized
disseminated
Age Infants under 1yr of age Children & young
adults
Adults & juvenile
Clinical
manifestati
ons
Enlargement of organs
and other swellings
Cachectic,petechiae &
necrotic ulcer ,severe
pancytopenia
3- bony lesions,
exophthalamus & DI
Male predominance
Oral
manifestati
ons
Necrotic ulcers
Petechiae
Mobility of teeth &
gingival bleeding
Ulcerations
Edematous gingiva
Loosened teeth
Destruction of dental follicle
Missing teeth
R/F Multiple small rounded
RL with well defined
borders
BL appear ragged n
may coalasce –
geographi c
appeareance
Proliferative periostitis,with
radiolucet ragged borders-
juvenile
Sclerosig borders in adults

Alveolar process Intraosseous
 Multiple
 Mandibular posterior
region
 Well defined without
cotiction
 Lesion starts from mid root
region of tooth
 Scooped out shape
 Solitary
 Mandibular ramus
 Well defined
 Shape is irregular or oval

Surrounding Structure
 Teeth appear to be standing in space
 The lesion does not displace teeth
 Periosteal new bone formation
 Can destroy outer ortical plate

Differential Diagnosis
 Periodontal disease
 Squamous cell carcinoma
 Simple bone cyst
 Metastatic malignant neoplasm
 Malignant tumors from adjacent soft tissues

Langerhans cell histiyocytosis

A panoramic film of multiple lesions of
Langerhans' cell histiocytosis. Note the scooped-out shape
of the bone destruction in the mandible. The floor of the
right maxillary antrum has been destroyed.

Skull lesions of Langerhans' cell histiocytosis, showing
well-defined, punchEd-out lesions.

Metastatic Carcinoma
Establishment of new foci of malignant disease
from distinct malignant tumour usually by the
way of blood vessels.
 1-3%of all metastasis.
 Women-from breast, adrenal gland, genital
organ, thyroid gland.
 Man-lung, prostate, kidney, adrenal gland

 Mand post region
 50-70 yrs of life
 Female predilection
 Oral neoplasm may be 1st sign of
malignancy-30%of cases.
 Enlarging tumours erode rapidly through
cortical plates.

Radiographic Features
1.A solitary well defined cyst like r/l
2.A solitary poorly defined r/l-localized,
3.multiple, separate, poorly defined r/l-
4.multiple,punched out r/l
5.r/o patterns with any of foregoing r/l
6.Irregular salt and pepper appearance-
7.A relatively dense, solitary, r/o area

 Secondary deposits from carcinoma may be
purely destructive(osteolytic) or they may be
bone forming (osteoblastic)
Osteolytic -2 types
 Frank destruction
 Infilteration
 Combination of area having bone destruction
and islands of bone
 Abnormality is centrally located

 2nd lytic type
Resemblance with osteomyeltis
Infilterated margins of areas of bone
destruction
Normal bone representng islands of various
sizes seperates the areas of bone destruciton
which is in continuity with the remaning
bone

AFFECT Of SURROUNDING STRUCTURES
 Periosteal reaction –speculated pattern
 Floating of teeth in air
 Extraction sockets fail to heal
 Resorption of teeth is rare
 Occasionally the tumor breaches into
surrounding soft tissue and present as an
intraoral mass
 Cortical borders of normal anatomical
structures are destroyed

D/D
 Multiple myeloma
 Odontogenic cysts secondarily infected
 Squamous cell carcinoma

references
 Principles practice oral radiologic
interpretation H.m worth
 Oral radiology principles and interpretation
5th edition white & pharaoh
 Differential diagnosis of orol and
maxillofacial lesions 5th edition norman.k
and wood,paul w.goaz

Multiple well defined radiolucencies / dental courses

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